What should field documentation include when recording vital signs and treatment?

• A. Document only the initial vital signs; ignore changes.
• B. Document vital signs at least once, but do not note changes.
• C. Record times and values for mental status, pulse, respirations, blood pressure if possible, and any changes; note symptoms, treatments given, and patient responses; obtain consent when possible.
• D. Document only the final outcome.

Answer: (C)

Accurate field documentation builds a running picture of how the patient is changing over time and what has been done to help them. When recording vital signs, include mental status, pulse, respirations, and blood pressure if you can obtain it, and write down the exact times and the numerical values, plus note any changes from previous readings. Also capture any symptoms the patient reports, the treatments you give, and how the patient responds to each intervention. If possible, obtain the patient’s consent and note that as well.

This approach matters because it lets you track trends and deterioration or improvement, guides decisions about further assessment, treatment, or evacuation, and provides clear information for others who may take over care. It also creates a record that can support decisions made in a challenging environment and, when possible, supports consent and patient rights. In the field, you may not have every measurement at every moment, but documenting what you have and any changes keeps the care trajectory clear rather than leaving gaps that could mislead future care.